C9397 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON PERMIT NUMBER
Ban LOING APPLICATION & PERMIT '9397���
ADDRESS
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNE U!;.""
L CHECK VALIDATION
NAME
O
, • TWO C �q PNONE OTV• ELECTRIC PERMIT FEE
J J
NAAMECONRAcroRs UTLETS-SWITCHES-RECEP 10.00/1.00
L �N LIC.NO, LIGHTING FIXTURES 10.00/1.00
ADDRESS oRs t qct/Z� PPLIANCES-RESIDENTIAL 4.00
PHONE -Zx0 PANELS 10.00 DATE OF APPLICATION
r CHUeCT ��/��/n /��^� _PLAN CHECK FEE P.C.NO.
oR C. Y '< Y PANELS (OVER 200 AMP) 20.00
ENGINEER ff'' r
LIC.No. 4D SIGNS TRANS. 3.00
ADDRESS ENG. DALO Ai� SPECIAL CIRCUIT 5,00 PERMIT VALIpAT10T�
!` A • r�Le
570 (r/770/J AdIL ZIP EMP.METER OR POLE INS. 20.00 AUG +
ADDRESS MOTORS SEE FEE SCH. F1
ADDRESS - 9985
SERVICE CHANGE 20.00
o o LICI,'NSI D CONI RACTORS DECLARATION TEMP.POLE 30.00 City Of Cupertino
< U I hereby affirm that I ren licensed under provisions of Chapter 9 ISSUANCE DATE
m z N (Commencing with Section 7000)of Eh isioo 3 of the Business and BLD ELECT. PLG. MECH.
r H z Professions Code mJ my licence is N full force Bed -lei[, ❑ ❑ ❑
0 o rn - License Class Lac.Number
4 N = w D'ulc Contractor
¢ Or w a C�UER UECLARATI N BUILDING PERMIT
X . H 1 hereby affirm Ilett I um exempt front Ore Contractor's License
MISC.- REFER TO ORD INFORMATION
a u o M Law for the fallowing reason(see 7031.5,Businessand Professions PERMIT ISSUANCE / VALUATION SIFT.
Code:Allcit Or Count which requires 10.00
E � > Y Y Y it 1 permit to ,also ,i
I[ Q ¢ p E]
improve,demolish,or repair any structure.prior to its issuance,also ELEC.CONTE. LIC.N0. TE'LET /UO
o: requires(he applicant for such permit to file a signed statement that TOTAL
6'X m u he is licensed pursuant to(he provisions of the Contractor's License D PERMIT TO
rii Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
z o Business and Professions Code)or that he is exempt therefrom and GTV- PLUMBING PERMIT FEENftuli
ar H m the basis for the alleged exemption.Any violation of Section 703L5 STORIES 'EYPEtoftTlF.
i 3 _ by any applicant for a permit subjects the applicant toacivilpenalty
ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more tltan five hundred dollars(55001.):
❑ Las owner of the properly,or my employees with I,nes BACK F LOW PROTECT.DEV ICE 4.00 OCC.GROUP RES.UNITS
m (S
their sole compensation,will the work,and the structure is not
' ended or offered for sale(Sec. 7044, Business and Professions
ho DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Cole:The Contractor's License Law does not to an owner of
property who builds or improves thereon.and who does such work FIXTURES-PER TRAP 5.00 so.FT FLOOR AREA TOTAL ACREAGE
• himself re of rote his own employees,provided that such improve-
oments
improvement tended or within
onefor
year
If. thebuildingowner-
GAS-EA.SVSTEM-11NC.40UTLET$ 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.1 2.00
proveer will have thr burden of proving that he did not build or ire- BUILDING USE
prove for purpose of role.). RES IND CON PB Other
' ❑ 1,as owner of the property,an,exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ Qd ❑ ❑
licensed contractors to construct the project(Sec.7044.Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORSP CEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of properly who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts I'or such projects with a contruaor(s)licensed pursuant to SEWER V-STORM EA.200f1/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ l ant exempt under Sec..,B.&PC,for(his WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE Ace FILE NO.
WORK Ii RS'COMPENSA'IION DECLARATION WATER TREATING EQUIP. 5.00
I hereby allium Thal 1 have a certificate of cou,mu to ClGiusnrc.
PC o certificate of Workers Compensation Ireurmme,or a certified ZONING ENG.SITE NO.
copy thercof(Scc.3800,Lah.C.). GA&
Policy No, Tpany - 10 778
O ❑ Cernied co Lt hcleby CoLS,- FIRE SPRINK ENERGY T-24
Z Z ❑ Certified c s f wiwill[[ Y" .pection divCsion.
F 0 Applicant MISC.- REFER TO ORD. Y ElN❑ Y El N❑
CC rn Cf: 'ICA'f O EX. IPI 106I7ROhI WORKERS' 'PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.uA.
W 1 CO. P.NSA7'[ON INSURANCE PLG.CONTE. LIC.NO. PLG.
d O (This secliun need not be completed if the lentil is for one TOTAL Y❑ N❑ Y _] NE]
Z hundred dollars IS 100)or less)
U O 1 certify that in the perfounarme of the work for which this per-
LL F mit is issued,I shall not employ any person in any manner so as to QTY. MECHANICAL PERMIT FEE FEE SUMMARY
U become subject to tiro Workers Compensation Laws of California.
U i Uat< ApplicantBUILDING
>- 00 NOTICE '1'O APPLICANT: If,after making this CerDBcele of Ex- ALTER OR ADD TO MECH. 5.00 .I
-
F 2 emption,you should become subject to the Workeri Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Tabor Code, you must forthwith comply with FEE
U such provisions or this permit shall be Jecmed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0,000GRM.) 6.00 SEISMIC FEE
I hereby of firm Tom there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address - ELECTRIC
I certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agfec to comply with all city and county PLUMBING
ordinances and state laws retailing to building construction, and BOILER-COMPO H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP Inver 100.000 BTU(BEE FEE SCH.
above-mmtlioned property for inspection purposes. MECHANICAL
(We) agree to save, indenmify a t keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgm rts, sts and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
nary i way ecme o inst id in consequence o the
grant guf tis pc tit. / MECH.CONT. LIC.NO. MECH.
_ �/ TOTAL TOTAL
sign . pphca Con IDclor [e
INSPECTOR COPY b
I